Retail Keg Registration Form Retailer Information:

Owner Name (Individual, Partnership, LLC, Corporation) Trade Name (Name listed on State Alcohol Permit)

Location Address (Street, City, State, & Zip Code) Permit Number

Sales Person Location Parish Business Phone Number

Purchaser Information: Name of Purchaser (print/type full legal name) ID#, State (Driver’s License, State ID, etc.) Phone Number

Date of Birth (month, day, & year) Age Residence Address (Street, City, State, & Zip Code)

Keg(s) Information (to be filled out by retailer): Date & Time of Purchase: at

Keg Identification Number(s): (1) (4) (2) (5) (3) (6) *NOTE: If the keg does not have an identification number, it is not authorized to be sold

under Louisiana Revised Statute 26:306. Was the purchaser’s identification thoroughly checked at the time the keg was Yes No purchased? If yes, what type of ID was checked? Check Type: Driver’s License State ID Military ID Passport/VISA Deposit: $

I, , am of legal age to purchase and possess this keg of alcoholic beverage

Print or type name (purchaser) identified above and will not knowingly allow any person under the age of twenty-one (21) years to

illegally consume this beverage. I will not obliterate, or allow to be removed the Identification Number

required on this keg.

Purchaser: Apply Signature Date

Retail Representative: Apply Signature Date

Date Keg Was Returned: Retailer Recipient (print/sign)

This form must be completed prior to purchaser receiving keg. Provide copy to purchaser. Original must be kept on file for not less than six months from the date keg is returned to retailer.

Louisiana Office of Alcohol & Tobacco Control ∙ 7979 Independence Blvd., Suite 101 ∙ Baton Rouge LA, 70806 ∙ PO Box 66404 ∙ Baton Rouge LA, 70896